First week of January 2023, Johnny, a 78-year-old Grandpa returned from the Christmas/New Year holidays in the Bahamas and came to the Richmond Hill office for his annual check-up. The visit went very well. Physical examination was unremarkable. Electrocardiogram showed no new changes. Blood tests were ordered and medications were renewed. I ended the visit with my usual smile, my signal that “it’s time to see my next patient, but grandpa remained seated and dropped a bombshell: “Doctor, I think I have syphilis!”
I looked at Johnny sharply: “you have what?” “Yeah, I had sex with this woman back in my home country two weeks ago, and then she told me she has syphilis”. I took the information in slowly, my head churning it. After practicing medicine for forty-three years, you would think you would have seen everything there is to see at least once, but this is a novel event: syphilis within two weeks of an actual documented exposure!
Your typical syphilis case is the young man or woman with the painless ulcer in the private part (the syphilitic chancre), or more usually a screening non-treponemal test like RPR turns up positive during a routine checkup, and you confirm the diagnosis with a treponemal test like FTA. These events usually occur months after exposure. So what do you do with someone with documented exposure only two weeks earlier?
It was a very busy morning, and I had no time to research the correct way to handle the situation. I was pretty sure that the screening test RPR was unlikely to be helpful. It takes 4-6 weeks to become positive after an infection. I was not sure when the confirmation FTA becomes positive, but if I ordered RPR, and it was negative, the lab would not bother to do the confirmation FTA test. So I ordered RPR, and FTA (not reflex, but must be done, irrespective of RPR result). The last question to be answered was treatment. The usual treatment for syphilis is high-dose Bicillin injection through a large calibre needle in the butt. The cost is prohibitive, north of $1000. The insurance would never approve that in the absence of a concrete diagnosis. So I chose the alternative treatment, doxycycline tablets twice a day for one month, usually reserved for those with penicillin allergy. It costs less than $30.
Johnny’s results came a few days later. Meanwhile, I checked the natural history of syphilis after exposure: just as I suspected, the screening RPR becomes positive in 4-6 weeks while the FTA which is used in confirmation, takes only 1-2 weeks to convert. Johnny’s result was exactly as expected for syphilis after two weeks: his RPR was negative while the FTA was positive. This means that if the woman had said nothing, and Johnny had his annual physical with the usual RPR only, and no FTA, he would have carried his syphilis for another year and infected all his consorts in that time period. It raises the question of when we should be screening with FTA, which becomes positive quickly, rather than RPR. A laboratory actually did that for my patients many years ago until I asked them to stop. Treponemal antibodies like FTA cross-react with many other non-treponemes Spirochetes in the soil, and many of my patients, especially Africans, had false positive treponemal antibodies. They had unnecessary tests and stress for syphilis they did not have. So, sadly, there is no perfect answer to this conundrum
This case reminds me of another funny syphilis case in an elderly patient. Grandma, 84, lived in Holland. In 2018, her daughter living in NY filed papers for her to come and live in America. Grandma came to my office to do the required Medical Examination by a Civil Surgeon before she could be allowed to be Permanent Resident. We did all the medical examinations and blood tests and grandma was asked to return for the completion of the 13-page USCIS form in three days.
When I checked Grandma’s result, I almost fell out of my chair. RPR positive 1:64; FTA Confirmation Test = Positive. As I reviewed the results, Grandma and her daughter, who was in her fifties, watched me closely. How on earth do you tell an 84-year-old Grandma that she had syphilis?
Clearing my throat, I avoided her peering gaze. “Excuse me Ma,” I began slowly. “There is a little bit of a problem. I had hoped to sign off on your case today, and give you your medical package for the USCIS. I am afraid there is an abnormality in your test. Ma, you have syphilis”. I finally was able to breathe again after completing my testy presentation. I waited for the earthquake and volcanic eruption to follow.
What happened next took me completely by surprise. Her daughter smiled and exclaimed: “So the Department of Health doctor was telling the truth after all!” “What?” “Yes, she had a medical examination done at the Public Dept of Health (where people with no medical insurance could go for free medical check-ups). They called her back that she has syphilis. We refused to believe it.”
With the second confirming opinion, Grandma came clean. She has a boyfriend in Holland, who services her regularly. I informed Grandma that she could not get her papers until we treat syphilis. We are going to need three shots of Penicillin every week for three. Since she had no medical insurance, I send her to the Department of Health for free treatment.
Syphilis is an old friend of randy mankind. Grandpa sang Tra la la, and Grandma was singing Tro lo lo.
Emmanuel O. Fashakin, M.D., FMCS(Nig), FWACS, FRCS(Ed), FAAFP, Esq.
Attorney at Law & Medical Director,
Abbydek Family Medical Practice, P.C.
Web address: http://www.abbydek.com
Cell phone: +1-347-217-6175
“Primum non nocere”
